ORIGINAL ARTICLE. Azreena Che Abdullah 1, Nor Afiah M.Z. 2 and Rosliza A.M 2

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1 ORIGINAL ARTICLE PREDICTORS FOR INADEQUATE KNOWLEDGE AND NEGATIVE ATTITUDE TOWARDS CHILDHOOD IMMUNIZATION AMONG PARENTS IN HULU LANGAT, SELANGOR, MALAYSIA Azreena Che Abdullah 1, Nor Afiah M.Z. 2 and Rosliza A.M 2 1 MPHCandidate, Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia. 2 Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia. CORRESPONDING AUTHOR: Nor Afiah binti Mohd Zulkefli norafiah@upm.edu.my ABSTRACT Vaccine hesitancy among parents has led to re-emergence of vaccine preventable diseases. In Malaysia, measles cases had increased by three times in 2015 compared to previous year. Immunization coverage has always been above 95% since However, in 2014, Mumps-Measles-Rubella (MMR) coverage has a significant drop to 93.4%. The aim of the study was to identify predictors for inadequate knowledge and negative attitude towards childhood immunization among parents in Hulu Langat, Selangor. A cross sectional study design was conducted from January to July 2016 with760 respondents. Respondents were selected by cluster random sampling and a validatedself-administered questionnaire was used. The majority of respondents were female (70%), Malay (87%), employed (92%) and parents with tertiary education (99.7%). In this study, 12.8% parents have an inadequate knowledge on childhood immunization and 47.6% parents have a negative attitude towards childhood immunization. The predictors for inadequate knowledge on childhood immunizations were last child s age of 2 years old or more (AOR= % CI ); parents without tertiary education (AOR= % CI ); parents withouteducational exposure on childhood immunization (AOR= % CI ) and parents who obtained information on childhood immunization from non-healthcare provider (AOR= % CI ). Predictors for negative attitude on childhood immunizations were being male (AOR= % CI ); parents without tertiary education (AOR= % CI ); household income of less than RM5000 (AOR= % CI ) and unsatisfactory religious belief (AOR= % CI ). Therefore, these predictors should be considered in any health intervention on childhood immunizations for parents in Malaysia. Keywords: Childhood immunizations, Parents, Knowledge, Attitude, Predictors, Malaysia INTRODUCTION Childhood immunization is one of the World Health Organizations (WHO) strategies in reducing children mortality and vaccine preventable diseases among children 1. Over the years, memory of dangerous infectious diseases has faded from public consciousness. A lack of personal experience with diseases like measles and pertussis and misinformation regarding vaccines, has led more parents to focus on adverse effect of vaccines rather than its benefits, thus refusing vaccinations 2. Vaccines hesitancy among parents started in 1998 after the later debunked article by Wakefield et al (1998) who allegedly reported an association between MMR vaccines and autism 3. In Malaysia, the growing number of parents refusing vaccination are worrying and exposing the country towards unnecessary risk. There are parents who believe that vaccination causes harm and dangerous for their children. It has been a serious debate in Malaysia between health care providers and parents who set up an anti-vaccine movement whom shares wrong ideas and wrong information regarding childhood immunization to other parents. Currently there are parents who believed that vaccination is haram and it is a conspiracy of the Jews. Parents knowledge on childhood immunization is very important to determine their attitudes towards uptake of immunizations 4. A study in the United States showed a significant difference in the knowledge between parents who did not delay or refused vaccinations compared to parents who refused or delayed vaccinations (p<0.005) 5. A retrospective cohort study in Iraq revealed that there was a significant association between adequate knowledge on childhood vaccinations and practises of completing immunizations among 286 parents studied 6. Many factors play important roles in influencing parents knowledge; one of it is having received educational intervention wherebyparents who had been educated on childhood immunization was reported to have a better knowledge on childhood immunization. A study in Hangzhou China reported that more than half of respondents (66.9%) did not know that vaccinations started since birth. After 1 hour of education intervention, 91.8% of respondents have answered correctly 7.

2 Another factor that was reported to influence parents knowledge on childhood immunizations isthe source of information obtained regarding childhood immunizations.studies have reported that parents who obtained information from healthcare providers were more likely to have better knowledge on childhood immunization 6,11. Another contributing factor towards childhood immunization is the parents attitude. As mentioned earlier, public attention has now shifted towards the risk of vaccines instead of their benefits. Various factors contribute to this shift including having a belief where their children are at low risk of contracting vaccine preventable diseases 8. A recent study in Malaysia reported that children whose mothers do not trust that vaccines can prevent spread of diseases were three times at higher risk of incomplete immunization 21. Another study in the United States of America (USA) documented similar findings that attitude, belief and behaviour of parents contribute in child immunization status 8.In addition, studies have showed that religious belief and source of information may influence the attitude of parents towards childhood immunization 11,16. This paper reports the predictors of inadequate knowledge on childhood immunization and negative attitude towards childhood immunization among parents in Hulu Langat district. METHODOLOGY Population Data was collected by visiting 28 registered child care centres under Department of Welfare in Hulu Langat, Selangor. Hulu Langat is one of the biggest districts in Selangor. There are 78 health clinics located in Hulu Langat district. Hulu Langat was chosen because this study would like to capture parents with higher level of education and lives in the urban or semi urban where health care services are abundance. Study Design and Sampling A cross sectional study was conducted from February to July Respondents were selected using cluster random sampling. Estimated sample size (N=860) was calculated using 2 proportions formula of Lwanga and Lemeshow, A complete list of registered child care centres was taken from Department of Welfare Malaysia. There were 100 registered child care centres in Hulu Langat district and 28 centres were selected by using table of random numbers with average of 30 to 35 children in each centre. All parents from the 28 registered child care centres, whom fulfil the inclusion criteria, were selected in this study and validated questionnaires were given to the principal to be distributed to all the parents. Inclusion criteria for this study were: Malaysian citizen; parents who have children aged 2 to 4 years old; parents either mother/father or caretaker and registered child care centre with Department of Social Welfare. The exclusion criterion for this study was immune-compromised children who are exempted from vaccinations. Study Instrument A self-administered questionnaire was used which comprises of questions on sociodemographic, 15 questions on knowledge and 13 statements on attitude of childhood immunizations. All questions were adopted from previous studies 6, 9, 10, 17, 18. Content validity of the questionnaires was assessed by 3 panels of experts which were 2 Public Health Specialist and 1 Family Medicine Specialist. The questionnaires were constructed in back to back translation which includes English and Malay language. Pretesting of the questionnaires was conducted in child care centres in Putrajaya and all of the respondents were excluded from the final study. The Cronbach Alpha for knowledge on childhood immunization questions was 0.70 and for attitude towards childhood immunization statements was For the assessment of knowledge on childhood immunization, parents were given choices yes, no and don t know answers. A score of 1 was given to any correct answers and 0 for incorrect and don t know answers. Maximum score was 15 and minimum score was 0. Mean score was (±3.04) and median score was (IQR 4). Since the total score was not normally distributed, thus cut off point for level of knowledge on childhood immunization was calculated based on its maximum and minimum score with the formula as below: [(Max. knowledge score + Min. Knowledge score)/2] + Min Knowledge score. The cut-off point was 7.5 which indicates that below 7.5 is inadequate knowledge on childhood immunization and 7.5 and above is adequate knowledge on childhood immunization. For the assessment of attitude towards childhood immunization,5 points Likert Scale was used. The scoring system used with respect to respondents responses as followed: strongly agree scored 5, agree 4, unsure 3, disagree 2, strongly disagree 1. Reverse scoring was used for the negative statements. The maximum score for attitude was 65 and the minimum score was 31. The mean score for attitude was (±5.80) and median was (IQR 8). Total score for attitude was not normally distributed therefore the cut-off point was calculated from the formula as below: [(Max attitude score + Min attitude score)/2 + Min attitude score] The cut off point for attitude was 48 which means above or equal to 48 was considered as

3 positive attitude towards childhood immunization while less than 48 was considered as negative attitude towards childhood immunization. The Duke University Religion Index (DUREL) is used to examine relationships between religion of a person and health outcomes. It is a fiveitem measure of religiousinvolvement and was developed for use in large cross-sectional and longitudinal observational studies. Data Analysis Data was analysed using SPSS Version 22. Descriptive statistical analysis was performed by using frequencies and percentage on all variables studied. Chi square test was used to measure associations between two categorical variables. All hypotheses tests were two-sided and the level of significance was set at Binary logistic regression was used for measuring the predictors of inadequate knowledge and negative attitude, with the confidence intervals set at 95%. Definition Healthcare provider: A person that provides health care services. In this study, the healthcare providers are the doctors, nurses, midwives and medical assistants. Education exposure on childhood immunization: An exposure or health talk on childhood immunization attended previously by the parents. RESULTS The response rate was 89.1%. Table 1 shows the socio-demographic characteristics of the respondents. The youngest respondent was 21 years old and the oldest respondent was 48 years old. Table 2 shows the respondents knowledge on childhood immunizations. The top 3 wrong answers given by parents were Healthy children do not need immunization (86.1%), Immunization can cause autism (56.1%) and Children get too many vaccines in the first two years of life (47.5%). While the top 3 for don t know answers given by the parents were Passive immunization is an antibody from someone who was infected with the disease (40.5%), Active immunization is a killed or weakened form of a disease-causing agent given to the children (40.0%) and Immunization can cause autism (38.8%). Table 3 presents the detailed response from all the respondents for attitude statements. In the positive statements (1-5), majority of respondents either answered strongly agree or agree for statements Compliance to immunization schedule is important, Child immunization is important and It is important for children to get all doctor-recommended vaccinations. In the negative statements (6-13), almost half of the respondents were not sure on these two statements; Too many vaccines could overwhelm a child s immune system and There has been not enough research on this vaccine. This study also found that the top three sources of information about childhood immunizations obtained by the parents were from the doctor (78.4%), nurses (53.4%) and the internet (46.7%). Majority of the respondents ranked source of information by doctors and nurses as excellent or good whereas for source of information from the internet, the majority of respondents ranked it as good or average. In this study, 87.2% respondent had an adequate knowledge and 52.4% of parents had a positive attitude. Factors associated with respondents knowledge and attitude on childhood immunisation The association between socio-demographic characteristics of respondents with their level of knowledge on childhood immunizations is shown in Table 1. Significant association were observed between respondents level of knowledge and their last child s age (p=0.002), gender (p=0.024), parent s education level (p=0.002) and household income (p=0.003). Table 1 also showed that gender (p=0.017), parents education level (p=0.002) and household income (p=0.001) have a significant association with level of attitude. Table 4 showed the association between educational exposure on childhood immunization and level of knowledge on childhood immunizations. Among respondents who have heard on educational talk regarding childhood immunization, majority of them (94.5%) have an adequate knowledge. There was a significant association between previous educational intervention with level of knowledge ( 2 = ; df=1; p=0.001). It is also showed an association between source of information and the level of knowledge among respondents. Respondents who obtained information from healthcare providers, 89.1% of them have adequate knowledge while those who obtained information on childhood immunizations from non-healthcare providers only 72% of them have adequate knowledge. It shows a significant association where 2 =19.29; df=1 and p value=0.001.

4 Table 1: Socio-Demographic Characteristics of The Respondents and Associations between Level of Knowledge and Level of Attitude on Childhood Immunization Characteristics Median (IQR) N (%) Level of Knowledge Level of Attitude Adequate n(%) Inadequate n(%) P Positive Negative P Age Respondent (5.0) to 29 years old 118(15.5) 102 (86.4) 16(13.6) 61(51.7) 57(48.3) 30 to 39 years old 560(73.7) 494 (88.2) 66(11.8) 300(53.6) 260(46.4) 40 to 49 years old 82(10.8) 67 (81.7) 15(18.3) 37(45.1) 45(54.9) Last Child Age (in year) 3.00 (3.0) 0.002* Age < 1 207(27.2) 184(88.9) 23(11.1) 109(52.7) 98(47.3) 1 < age < 2 160(21.1) 147(91.9) 13(8.1) 83(51.9) 77(48.1) 2 < age < 4 258(33.9) 227(88.0) 31(12.0) 146(56.6) 112(43.4) 4 < age < 5 135(17.8) 105(77.8) 97(12.8) 60(44.4) 75(55.6) Gender 0.024* 0.017* Male 228(30.0) 189(82.9) 39(17.1) 104(45.6) 124(54.4) Female 532(70.0) 474(89.1) 58(10.9) 294(55.3) 238(44.7) Parents Education Level 0.002* 0.002* Primary School 3(0.4) 1(33.3) 2(66.7) 1(33.3) 2(66.7) Secondary School 58(7.6) 45(77.6) 13(22.4) 20(34.5) 38(65.5) STPM /equivalent 33(4.3) 27(81.8) 6(18.2) 10(30.3) 23(69.7) Universities/equivalent 659(86.7) 585(88.8) 74(11.2) 364(55.2) 295(44.8) None 7(0.9) 5(71.4) 2(28.6) 3(42.9) 4(57.1) Household Income (RM) (4500.0) 0.003* 0.001* <5, (22.9) 144(82.8) 30(17.2) 69(39.7) 105(60.3) 5,000-7, (33.2) 219(86.9) 33(13.1) 121(48.0) 131(52.0) 7,001-9, (18.4) 116(82.9) 24(17.1) 65(46.4) 75(53.6) 9,001-11,000 96(12.6) 93(96.9) 3(3.1) 70(72.9) 26(27.1) >11,000 98(12.9) 91(92.9) 7(7.1) 73(74.5) 25(25.5) Number of Children 2.00(1.0) to 2 children 473(62.2) 408(86.3) 65(13.7) 254(53.7) 219(46.3) 3 to 4 children 245(32.2) 221(90.2) 24(9.8) 125(51.0) 120(49.0) > 5 children 42(5.5) 34(81.0) 8(19.0) 19(45.2) 23(54.8) Family Size 4.00(2.0) to 5 family members 570(75.0) 496(87.0) 74(13.0) 295(51.8) 275(48.2) 6 to 8 family members 169(22.2) 151(89.3) 18(10.7) 91(53.8) 78(46.2) >8 family members 21(2.8) 16(76.2) 5(23.8) 12(57.1) 9(42.9) Employment Status Employed 699(92.0) 610(87.3) 89(12.7) 365(52.2) 334(47.8) Unemployed 61(8.0) 53(86.9) 8(13.1) 33(54.1) 28(45.9) Note: (*) significant p<0.05, ( a ) Fischer exact

5 Table 2: Frequency and percentage distribution of respondents by knowledge questions Knowledge Statements Correct Wrong Don t Know Answers N % n % n % There are different types of childhood vaccines First dose in vaccination given at birth Most diseases against which children are vaccinated occur during the first years of life. There is a uniform immunization guideline for paediatric patients younger than two years in Malaysia. Most vaccines can be given in combination with other vaccines. Active immunization is a killed or weakened form of a disease-causing agent given to the children. Passive immunization is an antibody from someone who was infected with the disease. Scheduled vaccinations prevent children from some infectious diseases and its complications. Multi-doses of the same vaccine given at intervals are important for child immunity. More than one dose of vaccine may be required for complete protection. If child is having fever more than 38 degree Celsius, vaccines should not be given Immunization can cause autism Healthy children do not need immunization Children get too many vaccines in the first two years of life. Getting multiple shots in one visit can overload a child s immune system In Table 4, a significant association was found between source of information and the level of attitude towards childhood immunizationsand association between religious belief and level of attitude towards childhood immunizations among the respondents. It showed that respondents who obtained information from the healthcare providers have higher percentage (53.8%) of positive attitude towards childhood immunizations compared to respondents who obtained information from non-healthcare providers (40.2%).Respondents with satisfactory religious belief have higher percentage in positive attitude (63.2%) compared to respondents who have unsatisfactory religious belief (36.9%).

6 Table 3: Frequency and percentage distribution of respondent s attitude towards childhood immunizations Attitude Statements Compliance to immunization schedule is important. Immunizations keep your child healthy. Child immunization is important. It is important for children to get all doctor-recommended vaccinations. I have read or heard about problems with vaccine. Child immunization is prohibited in religion. Too many vaccines could overwhelm a child s immune system. Vaccines are given at too young of age. If I vaccinate my child, he/she may have a serious side effect. My children are at low risk for disease(s). The risk for adverse effects from this vaccine is too great. There has been not enough research on this vaccine. I do not think vaccines are effective in preventing disease(s). Strongly Agree Agree Not Sure Disagree Strongly Disagree n % n % n % n % n %

7 Table 4: Association between educational intervention, source of information and religious belief with level of knowledge and level of attitude on childhood immunizations Variables Adequate Knowledge Inadequate Knowledge P-value Positive Attitude Negative Attitude P- value n(%) n(%) n(%) n(%) Previous educational talk on childhood immunizations Yes 258(94.5) 15(5.5) 0.001* N/A N/A N/A No 405(83.2) 82(16.8) N/A N/A Source of Information Healthcare Provider 604(89.1) 74(10.9) 0.001* 365(53.8) 313(46.2) 0.026* Non-Healthcare Provider 59(72) 23(28) 33(40.2) 49(59.8) Religious Belief N/A N/A N/A 282(63.2) 164(36.8) 0.001* Satisfactory N/A N/A 116(36.9) 198(63.1) Unsatisfactory Note: (*) significant p<0.05; N/A: not applicable Predictors of inadequate knowledge on childhood immunization Table 5presents the predictors for inadequate knowledge on childhood immunizations. From the table, parents who have children less than 2 years old, the odds of having inadequate knowledge was 0.6 compared to parents who have children more than 2 years old (AOR=0.605; 95% CI ). Parents with no tertiary education were 2 times more likely to have inadequate knowledge on childhood immunization compared to graduates (AOR=2.020; 95% CI ). For parents without educational exposure on childhood immunization, the odds of them to have inadequate knowledge were 2.89 times higher compared to parents who have received previous educational exposure (AOR=2.890; 95% CI ). For source of information, parents who obtained information about childhood immunization from the non-healthcare provider were more than twice as likely to have inadequate knowledge (AOR=2.570; 95% CI ) compared to parents who obtained information about childhood immunization from health care providers. Predictors of negative attitude towards childhood immunisation Table 6showed the predictors of negative attitude towards childhood immunizations. The odds of male having negative attitude on childhood immunizations were 1.44 times higher compared to the female. Parents with no tertiary education were about twice more likely to have negative attitudes toward immunizations compared to parents with tertiary education (AOR= % CI ). For household income category, parents who have income less than RM 5,000 the odds of having negative attitude towards childhood immunizations was 1.85 times higher compared to parents who have household income more than RM 5,000 (AOR= % CI ). For parents who have a unsatisfactory religious belief, the odds of having negative attitude towards childhood immunizations was 2.76 times higher compared to parents who have satisfactory religious belief (AOR= % CI ). DISCUSSION Analysis of the demographic characteristics of the parents participated in the study showed that the majority of the respondents were female which is similar to what has been reported in previous studies 6,9,10. Gender was also significantly associated in both bivariate and multivariate analysis. In this study, it shows that mothers are about twice more likely to have adequate knowledge than fathers. This is most probably because the majority of the children were accompanied by their mothers during their visit to the clinics allowing mothers to receive adequate information regarding childhood immunization from the healthcare providers. While a contradicting result was reported from a study among parents in Iraq where fathers have better knowledge than mothers 6, another study by Awadh among 88 parents in Kuantan, Malaysia did not show significant association between gender and knowledge 10. From this study, understanding mother s knowledge and attitude towards immunization is important and health interventions should be focusing to mothers as their main participants. The majority of parents have tertiary education (86.7%).This study showed a significant association between higher level education and level of knowledge where parents with tertiary education were twice more likely to have

8 adequate knowledge. This finding is similar with results byawadh et al (2014) among Malaysia parents, Al-lela et al (2014) among parents in Iraq and Hu et al (2015) among parents in China. It is most probably because parents with higher education occupied an upper socioeconomic stratum which enables them to have better access to information from media, books and internet unlike lower education parents who are less fortunate to obtain information 6. Table 5: Predictors for Inadequate Knowledge Factors B SE Wald df p AOR 95% CI Last Child s Age > 2 years old * < 2years old 1 Education Level Non-Graduates * Graduates 1 Previous Educational Intervention No * Yes 1 Source of Information Non-Healthcare Provider * Healthcare Provider 1 Respondent s Age <35 years old >35 years old 1 Gender Male Female 1 Household Income < RM > RM Employment Status Unemployed Employed 1 Note: (*) significant p<0.05, (1) reference group In this study, household income of respondents showed a significant association in bivariate analysis however it was not significant in multivariate analysis. Overall, parents who have household income of more than RM 5,000 were associated with adequate knowledge. Lower household income and low level of education in a family might be barriers in access to effective communication and information from health providers 7. Studies from other developing countries reported that knowledge is significantly associated with household income 6,11. A study by Wang et al, 2007 among parents in province of Guangxi and Gansu China reported a significant association between knowledge and number of children and family size. The study found that knowledge scores increased when number of children and family increase because of the experience from the previous children. Similar findings were reported by Roodpeyma etal, 2007 among parents in Iran 12,13. However in this study, there was no significant association found between level of knowledge and number of children and family size.in this study parents who have received previous educational intervention regarding childhood immunizations have higher percentage of adequate knowledge compared to parents who did not received any educational intervention before. Majority of the respondents from this study received their educational intervention by doctors, nurses, assistant medical officer and others such as from non-governmental agencies. From the bivariate and multivariate analysis showed a significant association between level of knowledge and previous educational intervention where parents who have received previous educational intervention were almost 3 times was more likely to have adequate knowledge compared to parents who did not receive any educational intervention.

9 Table 6: Predictors for Negative Attitude on Childhood Immunizations Factors B SE Wald df p AOR 95% CI Gender Male * Female 1 Education Level Non-Graduates * Graduates 1 House Income < RM * > RM Religious Belief Non-Satisfactory * Satisfactory 1 Last Child s Age < 2years old > 2 years old 1 Source of Information Healthcare Provider Non-Healthcare Provider 1 Note: (*) significant p<0.05, (1) reference group The finding in this study is also consistent with the study conducted in Hangzhou, China and Kuantan, Malaysia 10,14. Study by Hu in 2014 reported that among 378 parents in Zheijang province, China there was a significant difference in their level of knowledge on childhood immunization before and after 1-hour seminar given by the healthcare personnel. There was a significant increase of 3.18 points (p<0.001) 14. While study by Awadh et al, 2014 reported that there was a significant increase in knowledge scores among 73 parents in Malaysia after 1 hour of educational talk by healthcare providers. The mean score before intervention was 6.84 ± 1.52 and after intervention was 9.15 ± 0.79 (p<0.001). From these two studies, it showed that educational intervention is an important strategy to improve parent s knowledge on childhood immunizations. Majority of the respondents obtained information regarding childhood information from the doctors, nurses and internet. Based on the quality of information, more than 60% of respondents said that information given by the doctors was excellent and good. Almost 50% of respondents answered that information given by the nurses was either excellent or good. As for internet more than half of the respondents answered either good or average. This explained that parents relied and trusted the information provided by healthcare personnel rather than the internet. This study showed a significant association between level of knowledge and source of information. Respondents who obtained information from healthcare providers have higher percentage (89.1%) of adequate knowledge compared to respondents who obtained information from non-healthcare providers (72%) and from the multivariate analysis showed that parents who obtained information regarding childhood immunization was about 3 times more likely to have adequate knowledge compared to parents who obtained information from non-healthcare providers. Research finding by Smith et al, 2006 also has similar result where healthcare providers contribute accurate information which leads to better knowledge and practice among parents 5. However, the above findings contradict from a study among parents in Iraq where majority of the parents preferred information by the television as it is freely available at their home 6. Analysis of level of attitude and demographic characteristic in this study showed that education level has a significant association with level of attitude on childhood immunizations (p<0.001). In the multivariate analysis showed that parents who have tertiary education are almost 2 times more likely to have positive attitude compared to parents who have low educational level. This finding was similar to a study by Deborah et al, 2005 among parents in United States 15. This could be possibly because parents with lower education level have difficulties to pose questions to healthcare providers in order to answer their worries or concern over childhood immunizations hence makes them having negative attitudes 15.

10 In this study, there was a significant association found between gender and level of attitude. Female was almost 1.5 times more likely to have positive attitude compared to male. This could be because majority of the respondents were female and most of them are the ones who brought their children to get immunizations and therefore have access to right information on childhood immunizations which leads to positive attitude. House income was also significantly associated with level of attitude in this study where parents who earned more than RM 5,000 were 2 times more likely to have positive attitude. In this study, majority of respondents who obtained information regarding childhood immunizations from the health care providers have positive attitude (53.8%) while parents who obtained information from non-health care providers such as the internet, media, family or friends majority of them have negative attitude (59.8%). However, there was no significant association between source of information and level of attitude. This result contradicts from other study where they found an association between parents attitude towards childhood immunization with source of information 19,20. Further studies can be done to assess its association. In a qualitative study in Canada among the Dutch, they believed that health status is determined by the God, most of them refused to get immunized as that will be as disobeying the God s will 16. From this study majority of the respondents have a satisfactory level of religious belief (58.7%) and it has significant association with level of attitude where respondents who have satisfactory religious belief are almost 3 times more likely to have positive attitude towards childhood immunizations. A limitation of this study is related to the study design. Being a cross sectional study, it onlyexamines the association or relationship but does not assess the causal direction of the relationships. This study also only represents Hulu Langat district where the characteristics of the population may differ from the population in other districts. Besides that, more factors should be included in future studies. CONCLUSIONS Based on findings of this study, the predictors of inadequate knowledge on childhood immunizations can be divided into intrapersonal factors and interpersonal factors. The intrapersonal factors are last child s age of 2 years old or more; parents without tertiary education and parents without educational exposure on childhood immunization. While for the interpersonal factor is parents who obtained information on childhood immunization from non-healthcare provider.therefore, healthcare providers may emphasize their competencies by attending continuous trainings or workshops so that all of them are skilful in conveying accurate information regarding childhood immunizations to parents. While the predictors for negative attitude on childhood immunizations can be grouped as intrapersonal factors. The predictors are being male; parents without tertiary education; household income of less than RM5000 and unsatisfactory religious belief. Religious belief has showed a significant association with positive attitude among parents therefore role of influential religious agencies may play an important part to persuade parents to be confident in immunizing their children. With this finding, health intervention strategy should invite and strengthen the role of influential religious bodies to ensure that parents are confident and have positive attitude towards childhood immunizations. ACKNOWLEDGEMENTS This study has gained approval from University Research Ethical Committee (JKEUPM), Universiti Putra Malaysia (Reference number: UPM/TNCPI/RMC/ (JKEUPM)/F2; Date: 27 th April 2016), and approval from the Principal of each child care centres. The authors would like to acknowledge all the Principals and parents involved in this study for their cooperation and support. The authors also would like to thank the Ministry of Health and the Department of Community Health for their institutional support throughout this study.we would like to thank the Director General of Health Malaysia for his permission to publish this article REFERENCES: 1. World Health Organizations Retrieved from mes_systems/en/ (accessed 5 March 2015) 2. Shimi E. Childhood Immunization Refusal: The Return of Vaccine-Preventable Diseases. J Vaccines Vaccin2012;3:e Yarwood J and Bozoky Z. Prevention through immunisation: take the evidence-based approach. Practice Nurse, 1998; 16(4): 216, AndreFE, Booy R, et al. Vaccination greatly reduces disease, disability, death and inequity worldwide. Bull World Health Organ 2008;86:

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